Dynamic Chiropractic Canada – August 1, 2014, Vol. 07, Issue 08

Is Your Practice at Risk?

By Drew Stevens, PhD

Operating a practice is such a lucrative decision. It is wonderful to be your own boss, yet most importantly, treat individuals who you desire to cure. Unfortunately, since you have decided to operate your own practice, there comes a myriad of responsibilities. Aside from the general use of policies and procedures, as well as staff implementation, there is also a vital need for risk management. And, in today's litigious society, it becomes increasingly important to manage risk in every single practice.

It might be best to determine what exactly risk is. By and large, risk management is the set of processes and procedures enculturated within the practice that ensure reasonably safe, secure and confidential care to the patient. Risk management also identifies, analyzes, evaluates and monitors actual and potential areas of risk associated with patients, always striving toward the prevention of any malpractice and its associated legal actions. The overarching goal for every office is to promote the safe delivery of high quality patient care, without penalization, injury or accident. Additionally, not only is risk management important for the doctor but also for every one of his staff.

patient records - Copyright – Stock Photo / Register Mark I was recently brought into a chiropractic office to review their risk assessment needs. Within the first few moments, I noticed there were patient files at the front desk. It was very easy for me to reach inside and obtain names and issues of current patients. This is a direct violation of HIPPA compliance and places the doctor in direct violation of risk. Since the topic is so broad and there are so many issues to review, I am choosing three of the most important for both new and experienced chiropractors.


Ask any doctor about their worst fears and annoyances and they will tell you that it is documentation. Documentation takes too much time and too much focus away from their daily efforts. Yet, for the doctor, documentation is vital to overall patient care. Whether you operate a cash or reimbursement practice, documentation proves your modalities, protocols and sequences for patient care as well as eradication of the patient's symptoms. Without documentation it becomes exceedingly difficult to gain reimbursement for services rendered.

It is known in the chiropractic profession that the standard documentation is Soap notes. And, ask many practice professionals and they will tell you that they are behind. It is impossible to provide complete and quality care to patients without good records. Without proper records, there is no way to provide your diagnosis, your intended treatments and your modalities to cure the patient. More importantly, what is the response to your care?

And when you lag behind in this critical foundation, you defer your billing, coding and reimbursement. Even if you do your own billing and coding, you are in critical violation of standard patient care. It would be most difficult to appear before a judge or an insurance company inquiry and indicate that you will lack the days ago in your documentation.

In order to justify continuing care, it is imperative that you record the patient's progress and your objective opinion. This is not an area that can be delegated to staff. You must do it! However, I do not want to provide a problem without a solution. Therefore, if you are poor at documentation, then utilize practice management software that is readily available and requires you to document a patient's diagnosis prior to checking out. There are numerous tools that offer this and you should review them today. If you were a student or your budget does not allow you currently to acquire this type of software, then you can utilize software and mobile applications such as Dragon Dictate or even Apple and Windows-based software tools that convert your voice into text. The sooner you gain access to these tools the more compliant you become.


Every patient that you see and treat deserves that all information remain confidential. This is not only the required ethical standard but also federal law. Most doctors today because of the small offices have very little storage and file space. However, when patient files are left available for others to see or even appointment sheets have patient names displayed, these all become violation of confidentiality. It is then incumbent upon the doctor and his staff to ensure that all patient information remain private.

First and foremost, all patient files should not only be placed at the front desk but rather behind the receptionist or chiropractic assistant so others cannot view them. All files along with their labels should also be placed down so that the backside is only showing, not displaying patient information. Staff should make this a common practice within their daily routine. Furthermore, files that are no longer needed for billing and coding should be immediately filed.

Second, there are times when employers, family members and even insurance companies desire to understand a patient's diagnosis. Both staff and the doctor should always err on the side of caution. No patient information should ever be released without the expressed written authorization of the patient. Further, only copies of the required information should be sent. Never release originals to anyone.

Third, at the beginning, middle and end of the day, we are all human beings. We all enjoy chat and even some rumor. What this means to you and your staff is that at no time are patient names, diagnosis and information to be spoken of amongst family, friends and peers. This is grounds for zero tolerance and immediate termination. Patients visit with you to be cured of their symptoms and not to be the target of conversation.

Office Management

Whether or not the doctor is a sole practitioner or has staff, there is no significance when it comes to risk management. In other words, the office must have a culture of confidentiality and adherence to ethical standards. What this means to the doctor can include but is not limited to: scheduling and rescheduling appointments and placing those appointments in a confidential file, ensuring that every patient has a file and all paperwork and administrative detail becomes part of that file, that every file has a diagnosis, a modality of treatment as well as the patient's consent for such treatment. Additionally, as it pertains to some of the information above, the patient also understands his or her obligations to pay and if reimbursement, the insurance company's obligation.

Secondly, when it comes to office management, some cultures and their environments are formal and others less informal. Yet, there is a gray area when it comes to riddles, jokes, current event information, political issues as well as touching, hugging, etc., as soon as a patient engages with the office as well as the doctor, there is a relationship. That said this relationship requires complete ethical and professional conduct. There are many times when conversations, touching and even implications seem to get out of hand. Boundary issues could be inadvertent but also tragic. Therefore, every single relationship a doctor has, which includes staff, must be maintained professionally. Anything less and the doctor and his staff will be subject to criminal charges.

Some of the methods that can be used to ensure proper protocols can include but are not limited to, a clearly written office procedures manual. This should also include a code of ethics that can also be displayed in the lobby or even in every treatment room. Secondly, we all understand that sometimes trouble can follow us. With that in mind, a doctor and staff need not accept every patient. Some patients appear more rigid than others and appear to be more problematic so there is much less room for gesticulation and implication. Therefore, the best method is to not accept them into the practice.

Best Practices

I am always asked what are some of the best practices and risk management. The easy answer is to be educated, in the moment and proactive. It is nearly impossible to plan for every issue that may come, but the more educated you are, the less fear you need to have. Always be aware of constant changes in federal and state laws as they pertain to these issues. It is also recommended you draft and always have available in your office ethical policies and practices that ensure your safety as well as your patients. The good doctor is well-educated and well prepared. They understand the value of risk, they embrace it and they constantly implement practices that ensure compliance.

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